10) Rheumatology (Part 2) Flashcards
1
Q
Polymyalgia Rheumatica
A
- Inflammation of synovial linings of bursae and joints especially at neck, shoulders and hips
- Elderly women with symmetric pain in neck, shoulder, pelvis is worse in morning
- PE limited active and passive ROM
2
Q
Polymyalgia Rheumatica diagnostics
A
- Labs Markedly Elevated ESR > 40, anemia
- Associated with Giant Cell Arteritis and Temporal Arteritis
3
Q
Polymyalgia Rheumatica Tx
A
- Treatment with steroids and NSAIDs
- Rapid response to steroids is usually noted
4
Q
Giant Cell Arteritis/Temporal Arteritis symptoms
A
- Headache
- Jaw claudication
- Pain and stiffness of shoulder and pelvis in 50%
5
Q
Giant Cell Arteritis/Temporal Arteritis physical exam/lab findings
A
- Check for temporal artery tenderness and bruit
- ESR and CRP rate high, normochromic normocytic anemia
6
Q
Giant cell arteritis Dx
A
- Diagnosis by temporal biopsy
7
Q
Giant cell arteritis Tx
A
- Glucocorticoids (before biopsy if strongly suspected)
- IV if vision loss at diagnosis
8
Q
Reactive Arthritis (Reiter’s)
A
- Mostly in men secondary to chlamydia urethritis or after GI infection by Shigella, Salmonella, Yersinia, Campylobacter
- Appears 1-4 weeks after infection
9
Q
Reactive arthritis symptoms
A
- Conjunctivitis
- Urinary symptoms possibly with shallow painless ulcers of glans penis
- Asymmetric arthritis of LE
- Dactylitis
- Low back pain
10
Q
Reactive arthritis labs
A
- Elevated ESR
- Leukocytosis
- Synovial fluid has WBCs, neutrophils
11
Q
Reactive arthritis x-ray may show
A
- Erosions
- Periosteal changes at tuberosities, Achilles tendon insertion
- Sacroiliitis
12
Q
Reactive arthritis Dx
A
- Clinical by history
13
Q
Reactive arthritis Tx
A
- NSAIDs
- Sulfasalazine
- Antibiotics only if there are signs of infection
14
Q
Rheumatoid arthritis
A
- Most common inflammatory arthritis, Women 25-55
15
Q
Rheumatoid arthritis joint findings
A
- Synovium infiltrated by inflammatory cells destroying cartilage
- Polyarticular – early symmetric small joints of hands and feet; also knees shoulders, elbows ankles and neck
16
Q
Rheumatoid arthritis symptoms
A
- Morning stiffness
- Fatigue
- Low grade fever
17
Q
Rheumatoid arthritis physical exam findings
A
- Swelling and thickening of MCP and PIP joints
- Subcutaneous nodules,
- Limited ROM and ulnar deviation at MCP is a late finding
18
Q
RA diagnosis ACR criteria
A
- Synovitis of at least one joint and scoring on others
- Arthritis of large and small joints,
- Symptoms over 6 weeks
19
Q
RA labs
A
- Elevated Sed rate
- 75% have positive RF
- Another serological marker is anti-citrullinatedpeptide/proteinantibody
20
Q
RA Tx
A
- Managed by a rheumatologist
- Goal is remission of inflammation
- Patient education helps management
- DMARDs are now started early, NSAIDs act faster (Methotrexate is the initial treatment given with folate)
- Disease severity fluctuates with “flares” so managed actively “tight control”
- Interarticular steroids, PT, braces, TJR
21
Q
Associations with RA
A
- Sjogren’s Syndrome
Felty’s Syndrome - Still’s Disease
22
Q
Sjogren’s Syndrome
A
- Decreased salivary, lacrimal gland secretion results in dry eyes and mouth
23
Q
Felty’s Syndrome
A
- RA with splenomegaly and leukopenia
24
Q
Still’s Disease
A
- Acute RA with fever, rash, splenomegaly and lymphadenopathy
- Remember Still’s can be a complication of JIA
25
Q
Systemic Lupus Erythematosis
A
- Autoimmune relapsing inflammatory multiorgan process in Women of childbearing age involving many systems
- Often presents with constitutional symptoms, photosensitive rash, and arthritis
- Neurological symptoms may include seizure or psychosis
26
Q
Manifestations of SLE
A
- Arthritis
- Rash
- Reynauld Phenomenon in 40%
- Cardiovascular
- Neurologic
- Ophthalmologic
- Hematologic
- Renal
- Pulmonary
27
Q
Diagnostic criteria for SLE (ACR 4 out of 11)
A
- Arthritis
- Pleuritis or pericarditis
- Photosensitivity
- Oral ulcers
- ANA most sensitive (almost always +)
- Malar “butterfly” rash
- Arthritis of 2 or more
- Anti-dsDNA, Anti-sm, VDRL
- CNS: siezures or psychosis
- Discoid rash
28
Q
SLE Tx
A
- Goal: prevent organ damage and improve quality of life
- Lifestyle modification- no smoking, sun exposure, good exercise, food, rest, NSAIDs
- Hydrochloroquine and cloroquine for mild skin and systemic
- Steroids for cutaneous and multiorgan damage
- Cyclophosphamide and azathioprine for severe
29
Q
Systemic sclerosis (scleroderma)
A
- Multisystem fibrosity of skin, blood vessels and viscera in 20-40 year olds
- Can be diffuse cutaneous or limited cutaneous
- Skin becomes thick and firm over SQ tissue, which leads to contractures
30
Q
Diffuse cutaneous scleroderma
A
- Thickening of skin on extremities, face and trunk
31
Q
Limited cutaneous scleroderma
A
- Only distal extremities and face, CREST
32
Q
Systemic sclerosis associations
A
- Reynaud’s phenomenon of vasoconstriction of arterioles of digits, nose and earlobes is the initial complaint in 65%
- Carpal Tunnel Syndrome
- Dysphagia
- Pericarditis and arrhythmias
- Renal failure
- Pulmonary on X-ray linear densities or “honeycombing”
33
Q
CREST syndrome
A
- Calcinosis cutis
- Raynaud phenomenon
- Esophageal dysmotility
- Sclerodactyly
- Telangiectasia
34
Q
Sjogren’s Syndrome
A
- Inflammation and destruction of salivary and lacrimal glands, dry mouth and eyes
- Primary or Secondary with RA or SLE
- Middle aged women “sand in eyes”
- Can get constipation and pancreatic insufficiency
35
Q
Sjogren’s Syndrome labs
A
- Anemia of chronic disease
- Leukopenia
- Mild eosinophilia
- ANA, RF, Anti-la, Anti-Ro
36
Q
Sjogren’s Syndrome Dx
A
- Salivary biopsy
37
Q
Sjogren’s Syndrome Tx
A
- Symptomatic
- Artificial tears and saliva
38
Q
Spondyloarthropathies
A
- Group of related diseases that includes:
- Inflammation of the axial joints (like sacroiliac)
- Asymmetric arthritis, dactylitis, enthesitis (inflammation tendon or ligament to bone), genital, skin, bowel, eye inflammation
39
Q
Examples of spondyloarthropathies
A
- Undifferentiated spondyloarthritis
- Ankylosing Spondylitis
- Reactive Arthritis
- Psoriatic arthritis
- Spondyloarthropathy of inflammatory bowel disease
- Juvenile spondyloarthitis
40
Q
Ankylosing spondylitis (axial spondyloarthritis)
A
- Chronic inflammatory disease of the axial skeletal joints, progressively ascending, “bridging of discs”
- Disease presents between ages 20-30
- 2-3 times more common in men than women
41
Q
Ankylosing spondylitis signs and symptoms
A
- Acutely: pain and stiffness
- Chronically: fusion of vertebrae with decreased ROM
- Presents in early adulthood with intermittent diffuse low back pain and morning stiffness, with decreased ROM
42
Q
Axial spondyloarthritis physical exam findings
A
- Restricted spinal or chest mobility
- Painless joint effusion
- Sacroiliac tenderness
- Schober test (for lumbar forward flexion)
- Occiput to wall distance (for degree of cervical flexion deformity)
- Late characteristics: Extreme kyphosis, spine and thoracic expansion
43
Q
Occiput to wall distance
A
- The distance between the occiput and the wall is a measure of the degree of flexion deformity of the cervical spine
44
Q
Axial spondyloarthritis Dx studies
A
- HLA-B27 positive in 90-95%, but there are false-positives,
- Elevated ESR/CRP
- X-ray abnormal AP view of SI joints (sacroiliitis)
- X-ray “Bamboo Spine” secondary to fusion and generalized osteopenia,
- MRI can confirm axial spondyloarthiritis in 80-95%
45
Q
Axial spondyloarthritis Tx
A
- NSAIDs dramatically improve symptoms,
- Physical therapy and exercise to preserve ROM, oral or injected steroids,
- Surgically, Osteotomy
46
Q
Psoriatic arthritis
A
- Arthritis in a psoriasis patient
- 30% of psoriasis patients get psoriatic arthritis (HLA-B27 predicts which get arthritis)
- Most psoriatic arthritis patients get nail issues like nail pits and onycholysis
- Some have positive ANA , RF
47
Q
Typical psoriatic arthritis
A
- 30 year old with insidious onset of peripheral arthritis, “sausage” fingers, history of cutaneous psoriasis (may be remote), joint swelling, tenderness, nail changes like pitting, traverse ridging, onycholysis, involvement of sacroiliac joint or ankylosing spondylitis, dry erythematous papular regions or conjunctivitis
48
Q
Psoriatic arthritis x-ray
A
- Osteolysis
- DIP “pencil-in-cup” deformity
49
Q
Psoriatic arthritis Tx
A
- Symptomatic
- PT, NSAIDs, DMARDs, methotrexate, TNF inhibitors
50
Q
Paget’s Disease (osteitis deformans)
A
- Overactive osteoclasts (osteolytic lesions)
- Frontal bossing and shortened spine
- Elevated alk phos
- “Cotton wool” appearance of skull on xray
51
Q
Paget’s Disease Tx
A
- Bisphosphonates
